What do you do when therapy seems to be getting stuck?

I wonder if you have ever had this kind of scenario play out in front of you?  The GP has referred a client to you, let’s call her Joanna, who has a Mental Health Care plan saying she is struggling with an adjustment disorder following a relationship breakdown.  Joanna is keen to get help so she can get back to feeling like her old self.

You conduct a detailed intake session, get the relevant history and book Joanna in for five more regular sessions before the Review is due with the GP.

Joanna seems to go along with the plan as it is so difficult to get in for psychologists and counsellors at the moment.

The next week you greet Joanna warmly and pull out the Daily Mood Log so she can get to work learning the thought distortions which are contributing to her distress.  After all, you have got a lot of very powerful strategies to help Joanna and it is upsetting to see her in distress. You want to be accountable and get to work.

It is a bit of a surprise when Joanna, who seemed so pleasant, now crosses her arms and talks in monosyllables.  Eventually, she sighs and says “I don’t want to see you again. This is not helping at all and you don’t seem to understand or even care!”

What do you do? 

  1. Rush to convince Joanna that she is wrong and that of course, you care?
  2. Apologise profusely?
  3. Continue with the Daily Mood Log so she can get some benefit?
  4. Stop and fall back to empathy to invite her to talk more about how she feels?

Option 4, falling back to empathy is the best way to continue. In fact, I believe it is the only way to repair the rift and allow for an ongoing helpful therapeutic relationship.  That must happen before anything else.   But responding with empathy is difficult to do because no one likes to admit they made a mistake.  Therapists are not immune to our evolutionary heritage which primes us to get defensive or want to attack when we feel threatened or criticised.

I expect this situation would occur less often with TEAM-CBT clinicians who have received explicit training in how to respond with empathy in just such difficult situations.

In his ebook, Tools not Schools of Therapy, David Burns tells the story of watching his student Stirling, a gifted communicator, connect with every single patient who consulted with him.  Stirling did not know about CBT but he knew how to engage people in conversations whatever the topic and whatever the oddness in the thought process.

In a lovely spirit of humility and desire to learn, David took notes, wrote out transcripts of conversations and categorised the strategies Stirling used to build empathy.  David called these the Five Secrets of Effective Communication and they cover the basic micro-skills for counselling (Burns 1991, 1992). He uses the acronym DEAR as a memory tool.  I like to remember DEAR as the way to communicate with someone who is very DEAR to you.

Effective communication starts with good listening skills. It is helpful to remember the old saying you have two ears and one mouth so listen more than you speak.

Once you have listened, it is suggested that you practice;

D: Disarming the other person by finding some truth in what they say even when it seems unfair or untrue.

E: Empathy: trying to see the situation from their viewpoint by putting yourself in their shoes. It has two elements:

  1. Thought empathy- paraphrasing or repeating their actual words
  2. Feeling empathy- acknowledging how they are probably feeling

Self Expression skills are also important so you do not remain hidden from the other person.  You need to use:

A: Assertion skills  such as I feel statements eg “I feel a bit sad”

R: Respect  Convey an attitude of respect even in the heat of battle or conflict.  This involves Stroking: find something genuinely positive to say about the other person.

You can follow with Inquiry: asking gentle questions to invite them to tell you more about what they are thinking and feeling.

One possible response we could provide to Joanna using these skills would be:

“Joanna, you are right. (Disarming) I did jump into my plans too fast before taking time to really listen to you.

I hear you saying you don’t want to see me again, you don’t think this is helping, and that I don’t seem to understand or even care. (Thought empathy)

I feel bad about ( Feeling empathy) as I respect you a lot and appreciated the way you made time to fit these sessions into your schedule. ( Stroking)

I guess you are probably feeling pretty annoyed with me and disappointed with this whole situation. ( Feeling Empathy)

Is that right?  Could you tell me a bit more about how you are feeling now and what has been happening for you( Inquiry)

The Five Secrets of Effective Communication do not always work.  They can backfire horribly if used in a phoney or manipulative manner.  However, when used with a genuine desire to build closer relationships, these skills are incredibly effective.  They can help you to get therapy back on track with your clients.   I am excited about the success of the Five Secrets to help my clients and trainees to improve their personal and work relationships.

If you want to learn how to communicate with those DEAR to you, click here for details about training options in Australia.

Warmly, Robyn Blake-Mortimer

TEAM-CBT Therapist and Trainer (Level 4)